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386: Cost-effectiveness of antenatal late preterm steroids with and without tocolysis
Poster Session II human epididymal protein-4, kallikrein-5, cathepsin B and extracellular matrix metalloproteinase inducer. Cervical length was evaluated by transvaginal ultrasound using two techniques: measuring the linear straight distance between the internal and external os, and adding the sum of two linear contiguous segments tracing from the internal to the external os. Three measurements were taken for each woman and the shortest cervical length was used. Associations between cervical length and vaginal compounds were analyzed by Spearman rank correlation. RESULTS: Thirty five women at 18-24 weeks gestation were evaluated so far. Cervical length was negatively associated with the MMP-2 level (p¼0.0157) and positively correlated with the D-lactic acid level (p¼0.0146). There was a strong negative association between D-lactic acid and MMP-2 levels (p¼0.0057). There was no relationship between gestational age at sample collection and Dlactic acid or MMP-2 levels or between cervical length and maternal age, gravidity, parity, history of abortions and sludge in the amniotic cavity. CONCLUSION: Elevations in MMP-2 that are associated with cervical shortening in the mid-trimester are prevented when high levels of D-lactic acid are present. D-lactic acid is produced in the vagina by L. crispatus, L. jensenii and L. gasseri, suggesting that the abundance of these bacteria may help prevent decreased cervical length by reducing MMP-2 production.
386 Cost-effectiveness of antenatal late preterm steroids with and without tocolysis Vanessa R. Lee1, Anjali J. Kaimal2, Aaron B. Caughey1 1
Oregon Health & Science University, Portland, OR, 2Massachusetts General Hospital, Boston, MA
OBJECTIVE: Corticosteroids have been shown to reduce the risk of
respiratory morbidity in pregnancies at risk of late preterm birth. However, recent data supporting this strategy did not examine whether tocolysis impacted outcomes. The purpose of this study was to determine whether adding tocolysis to a course of antenatal late preterm steroids in women at risk of late preterm delivery is an optimal or cost-effective strategy compared to steroids alone. STUDY DESIGN: We created a decision-analytic model using TreeAge software to compare antenatal late preterm steroids with and without tocolysis in a theoretic cohort of 10,000 women at risk for delivery at 34, 35, and 36 weeks’ gestation. All probabilities and costs of care were derived from the literature. Outcomes included severe respiratory morbidity (a composite of respiratory distress syndrome, transient tachypnea of the newborn, and apnea), neonatal death, total costs, and quality-adjusted life years (QALYs). A willingness-topay value of $100,000 per QALY was the threshold for cost-effectiveness in our model. RESULTS: In our theoretic cohort, the addition of tocolysis to a course of antenatal betamethasone would prevent 274 cases of respiratory morbidity if given at 34 weeks, 190 cases at 35 weeks, and 86 cases at 36 weeks. Furthermore, strategies involving tocolysis resulted in fewer neonatal deaths, thereby optimizing QALYs at each gestational age. Regardless of the gestational age at which steroids were initiated, adding tocolysis was a more expensive strategy. However, compared to steroids alone, steroids plus tocolysis was incrementally cost-effective at $1854/QALY at 34 weeks, $4670/QALY at 35 weeks, and $14,362/QALY at 36 weeks. CONCLUSION: This decision-analytic model suggests that while adding tocolysis to corticosteroids is more costly, it would reduce neonatal morbidity and mortality and thus be a cost-effective intervention
ajog.org compared to steroids alone. Additional clinical trials investigating the addition of tocolysis in the setting of late preterm steroid administration are warranted in order to more fully inform management of these pregnancies.
387 Cost-effectiveness of post-cesarean pharmacologic VTE prophylaxis in obese women Vanessa R. Lee1, Gina L. Westhoff2, Rachel A. Pilliod1, Keenan E. Yanit1, Aaron B. Caughey1 1 Oregon Health & Science University, Portland, OR, 2Legacy Health, Portland, OR
OBJECTIVE: Obese women are at increased risk of venous thrombo-
embolic events (VTE) after cesarean delivery, but outcome and cost data are lacking to definitively recommend an optimal strategy for VTE prophylaxis. The purpose of this study is to compare obstetric outcomes and cost-effectiveness of post-cesarean VTE prophylaxis with low molecular weight heparin (LMWH) plus intermittent pneumatic compression devices (IPCs), versus IPCs alone, in an obese population. STUDY DESIGN: We built a decision-analytic model comparing prophylactic IPCs versus IPCs plus LMWH in a theoretic cohort of 100,000 obese women undergoing cesarean delivery. All model inputs were derived from the literature. Outcomes included maternal death, VTE events, heparin-induced thrombocytopenia (HIT), major hemorrhage, recurrent VTE, costs, and quality-adjusted life years (QALYs). Base case, cost-effectiveness, and sensitivity analyses were performed, and additional analyses were performed to investigate the impact of morbid obesity (BMI >40) and emergent cesarean delivery on the model outcomes. RESULTS: Compared to IPCs alone, adding LMWH would prevent 448 VTE events, 11 cases of recurrent VTE, and 5 maternal deaths. This strategy also optimized total QALYs. Although adding LMWH was three times as expensive and would result in higher rates of hemorrhage and HIT, LMWH plus IPCs was ultimately incrementally cost-effective compared to IPCs alone at $88,001 per QALY. Furthermore, LMWH plus IPCs was increasingly cost-effective in obese women undergoing emergent cesarean ($54,626/QALY), morbidly obese women ($43,056/ QALY), and morbidly obese women undergoing emergent cesarean ($26,569/QALY). CONCLUSION: In obese women, post-cesarean VTE prophylaxis with IPCs plus LMWH is more costly but improves outcomes, and is thereby a cost-effective strategy compared to IPCs alone, particularly in cases of morbid obesity and emergent cesarean delivery.
S232 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017
386 Cost-effectiveness of antenatal late preterm steroids with and without tocolysis Vanessa R. Lee1, Anjali J. Kaimal2, Aaron B. Caughey1 1
Oregon Health & Science University, Portland, OR, 2Massachusetts General Hospital, Boston, MA
OBJECTIVE: Corticosteroids have been shown to reduce the risk of
respiratory morbidity in pregnancies at risk of late preterm birth. However, recent data supporting this strategy did not examine whether tocolysis impacted outcomes. The purpose of this study was to determine whether adding tocolysis to a course of antenatal late preterm steroids in women at risk of late preterm delivery is an optimal or cost-effective strategy compared to steroids alone. STUDY DESIGN: We created a decision-analytic model using TreeAge software to compare antenatal late preterm steroids with and without tocolysis in a theoretic cohort of 10,000 women at risk for delivery at 34, 35, and 36 weeks’ gestation. All probabilities and costs of care were derived from the literature. Outcomes included severe respiratory morbidity (a composite of respiratory distress syndrome, transient tachypnea of the newborn, and apnea), neonatal death, total costs, and quality-adjusted life years (QALYs). A willingness-topay value of $100,000 per QALY was the threshold for cost-effectiveness in our model. RESULTS: In our theoretic cohort, the addition of tocolysis to a course of antenatal betamethasone would prevent 274 cases of respiratory morbidity if given at 34 weeks, 190 cases at 35 weeks, and 86 cases at 36 weeks. Furthermore, strategies involving tocolysis resulted in fewer neonatal deaths, thereby optimizing QALYs at each gestational age. Regardless of the gestational age at which steroids were initiated, adding tocolysis was a more expensive strategy. However, compared to steroids alone, steroids plus tocolysis was incrementally cost-effective at $1854/QALY at 34 weeks, $4670/QALY at 35 weeks, and $14,362/QALY at 36 weeks. CONCLUSION: This decision-analytic model suggests that while adding tocolysis to corticosteroids is more costly, it would reduce neonatal morbidity and mortality and thus be a cost-effective intervention
ajog.org compared to steroids alone. Additional clinical trials investigating the addition of tocolysis in the setting of late preterm steroid administration are warranted in order to more fully inform management of these pregnancies.
387 Cost-effectiveness of post-cesarean pharmacologic VTE prophylaxis in obese women Vanessa R. Lee1, Gina L. Westhoff2, Rachel A. Pilliod1, Keenan E. Yanit1, Aaron B. Caughey1 1 Oregon Health & Science University, Portland, OR, 2Legacy Health, Portland, OR
OBJECTIVE: Obese women are at increased risk of venous thrombo-
embolic events (VTE) after cesarean delivery, but outcome and cost data are lacking to definitively recommend an optimal strategy for VTE prophylaxis. The purpose of this study is to compare obstetric outcomes and cost-effectiveness of post-cesarean VTE prophylaxis with low molecular weight heparin (LMWH) plus intermittent pneumatic compression devices (IPCs), versus IPCs alone, in an obese population. STUDY DESIGN: We built a decision-analytic model comparing prophylactic IPCs versus IPCs plus LMWH in a theoretic cohort of 100,000 obese women undergoing cesarean delivery. All model inputs were derived from the literature. Outcomes included maternal death, VTE events, heparin-induced thrombocytopenia (HIT), major hemorrhage, recurrent VTE, costs, and quality-adjusted life years (QALYs). Base case, cost-effectiveness, and sensitivity analyses were performed, and additional analyses were performed to investigate the impact of morbid obesity (BMI >40) and emergent cesarean delivery on the model outcomes. RESULTS: Compared to IPCs alone, adding LMWH would prevent 448 VTE events, 11 cases of recurrent VTE, and 5 maternal deaths. This strategy also optimized total QALYs. Although adding LMWH was three times as expensive and would result in higher rates of hemorrhage and HIT, LMWH plus IPCs was ultimately incrementally cost-effective compared to IPCs alone at $88,001 per QALY. Furthermore, LMWH plus IPCs was increasingly cost-effective in obese women undergoing emergent cesarean ($54,626/QALY), morbidly obese women ($43,056/ QALY), and morbidly obese women undergoing emergent cesarean ($26,569/QALY). CONCLUSION: In obese women, post-cesarean VTE prophylaxis with IPCs plus LMWH is more costly but improves outcomes, and is thereby a cost-effective strategy compared to IPCs alone, particularly in cases of morbid obesity and emergent cesarean delivery.
S232 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017